Inspection on 04/07/06 for St Anne`s

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Anne`s 29/11/06

St Anne`s 12/01/06

St Anne`s 07/07/05

St Anne`s 03/02/05

St Anne`s 27/07/04

St Anne`s 25/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Anne`s 21 Wayside Road Southbourne Bournemouth Dorset BH6 3ES Lead Inspector Jo Palmer Key Unannounced Inspection 10:45 4th July 2006 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000020496.V303316.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000020496.V303316.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Address 21 Wayside Road Southbourne Bournemouth Dorset BH6 3ES 01202 425642 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr M J Lingam-Willgoss Mrs N Lingam-Willgoss Mrs N Lingam-Willgoss Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places DS0000020496.V303316.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: St Annes is a care home providing nursing and personal care for up to eighteen older people. Situated in a quiet residential road in Southbourne close to local amenities. There are sixteen single rooms, eight of which have en-suite facilities and one double room. There is a communal lounge area on the first floor although this is not used very much by service users, a desk at one end provides staff with office space. A passenger lift and two staircases provide access between the floors. A kitchen is centrally sited on the ground floor from which all meals are prepared and other utility areas (laundry and food stores are in an adjacent building. Outside the home there are small gardens to the front and rear with a small parking area to the front. Mr and Mrs LinghamWilgoss are the registered providers (owners) of St Annes, and Mrs LinghamWilgoss also takes the role of manager with the support of a deputy manager. DS0000020496.V303316.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 4th July 2006 lasted for four and half hours. Mrs Lingham-Wilgoss registered provider and manager was taking a day off, the deputy manager assisted with the inspection. The inspector also spoke with six residents and briefly with five members of staff, examined relevant records and took a tour of the premises. This was a ‘key’ inspection where the home’s performance against the key National Minimum Standards was assessed along with progress in meeting requirements of the last inspection. A pre-inspection questionnaire was sent to the manager in order that certain information could be provided, questionnaires were also sent to the home prior to the inspection to be distributed to residents, relatives and visiting health care professionals, the pre-inspection questionnaire had not been returned at the time of inspection. Ten questionnaires were returned from residents, five from relatives, two from care managers and one from a local GP, their responses, along with observation and discussion with residents will inform parts of this report. What the service does well: Residents reported that they feel comfortable and well cared for at St Anne’s, needs are assessed and identified although comment has been made with regard to how the assessment and care planning process can be improved. Residents confirmed they felt respected and their rights to privacy were upheld, they stated they feel able to make decisions about their lives in the home and daily routines and are able to receive visitors freely. Social care is limited but again, residents confirmed that the home’s social arrangements meet their expectations. Meals are provided to residents in their rooms and a variety of dishes are served, residents confirmed that the food is good and appetising. The environment is pleasant, clean and well maintained, residents bedrooms are appropriately furnished and decorated and residents are able to benefit from bringing some of their own items to personalise their space. There are sufficient numbers of staff on duty to provide support to residents; some training programmes are in place although these need developing. Mrs Lingham-Wilgoss has the experience and qualifications to manage the home and is supported by a senior staff team, quality assurance methods are being developed. DS0000020496.V303316.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Fifteen requirements are made as a result of this inspection, five of which are repeated from the last inspection dated 12th January 2006. This inspection has resulted in the Commission having concerns about the service provision, failure of the registered persons to address the requirements in this report by the time scales specified may lead to enforcement action being taken against them. Prior to moving to St Anne’s, prospective residents must be provided with all the necessary information in order that they can make an informed choice about deciding whether they want to live there. This must include a detailed, up to date, Statement of Purpose and Service User Guide which includes a copy of the most recent inspection report, and confirmation from the home that, based on the assessment, that the home is able to meet their needs. Care must be planned and delivered systematically and where intervention is required for specific health care needs where risks are identified, staff must be informed of corrective action needed to reduce those risks. Medication held in the home must be managed according to Royal Pharmaceutical guidelines. As part of the assessment and care planning process, residents must be consulted about care outcomes in order that they can make personal choices and decisions about their care, this is to include social care and meal arrangements including access to a written, accurate menu. Residents must be provided with detailed information regarding the complaints process; the procedures for staff must detail the action to be taken on receipt of a complaint. Adult protection procedures must be in place in accordance with local authority guidelines and staff must be aware of, and receive training in matters pertaining to abuse and adult protection protocols. Staff training programmes must be developed to ensure all staff are trained to the National Occupational Standards for care staff in order for them to be able to demonstrate they have the skills and knowledge to meet residents needs. DS0000020496.V303316.R01.S.doc Version 5.2 Page 7 Quality assurance programmes must be developed and the views of residents, their representatives, health care professionals and staff must be audited to ensure effective measurement of the care and services provided against the home’s aims and objectives. For the protection of residents and confidentiality, records must be up to date, accurate and kept in the home at all times. The health and safety of residents must be protected by the training of staff in areas relating to food hygiene, general health and safety, infection control and COSHH 2002. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000020496.V303316.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000020496.V303316.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4. Standard 6 is not applicable. Quality in this outcome area is adequate; this judgement is made using available evidence. There is no comprehensive, reliable information available to residents prior to them moving to the home, the admissions process is such that residents needs are assessed before moving to St Anne’s although residents are not informed, in writing that based on the findings of the assessment, the home can meet their needs. EVIDENCE: The home’s information pack, or Service User Guide, was examined, this contains some relevant information although this is out of date and has not been reviewed, the information is only available to residents on request, from the office area of the home where it is kept. During the inspection, a telephone enquiry for a placement was received by the home, the deputy manager agreed to send a copy of the home’s brochure, which she stated, had been updated to make reference to the registering authority. The brochure as seen, did not provide the information a prospective resident should expect when making a decision to move to a care home. DS0000020496.V303316.R01.S.doc Version 5.2 Page 10 Of four residents care files examined, just one had been admitted to the home in the previous six months, this resident had assistance with her funding arrangements and as such had a pre-admission assessment undertaken by the funding authority and primary care trust prior to moving to St Anne’s. Following her move to the home, the resident had various further assessments undertaken in order to identify her needs. These assessments of need, and those of the other three residents whose care files were examined, showed no evidence of the resident’s, or their representative’s, participation in the assessment process or agreement with the identified care outcomes. Assessments did not identify the source of the information or any further guidance or support required, for example, where nutritional assessments identify a high risk of poor nutrition, the instruction is to ‘seek dietetic advice’, there was not evidence that this advice had been sought. Residents were not informed that based on the assessments, the home is suitable for meeting their needs, Mrs Lingham-Wilgoss has since confirmed that a new letter has been introduced that will be sent to residents following assessment. DS0000020496.V303316.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor; this judgement is made using available evidence. The care planning system is unwieldy and does not provide staff with sufficient information to meet resident’s needs. The procedures for managing medication are not always in line with Royal Pharmaceutical guidelines. Resident’s rights to privacy are supported through care delivery and relationships with staff. EVIDENCE: Some care plans examined held comprehensive information about meeting a persons needs in respect of personal choices and care routines, these provided detailed instruction to staff as to how needs were to be met. Care plans are reviewed following assessment and recorded entries demonstrate changes in a person’s health and welfare. However, all four of the care files examined identified the residents at being at ‘high risk’ or ‘very high risk’ in relation to adequate nutrition, there was no associated care plan or dietetic advice sought DS0000020496.V303316.R01.S.doc Version 5.2 Page 12 in relation to this. A monthly record of each residents weight is kept and it was evident that two of the three had gained weight. A dietary care plan for one resident indicated that staff must ‘offer little and often’, provide a soft diet and ‘encourage fluids’, there was no indication of the optimum amount of fluid needed for this resident. A requirement of the last inspection is repeated with regard to catheter care, it was evident that a new format is being introduced although this is not yet operational; currently, care plans for residents who require catheter care are not sufficient, they do not indicate frequency of catheter change, size of catheter to be used, frequency of bladder washout and each care plan states that output should be recorded although input (amount of fluids taken) is not. Daily records of care provided demonstrate each residents daily lives in the home to some extent with regard to personal care although many entries state ‘care given as planned’, as some care plans are not detailed sufficiently, this statement is inadequate. Care records demonstrate the extent to which medical intervention has been required and appointments are held with visiting GP’s, chiropodists, opticians etc. Residents spoken with and questionnaires returned form residents, relatives and care managers all indicated that they were satisfied with the level of care provided and it was evident from meeting with residents during the inspection, that on an exceptionally hot day, plenty of fluids were being encouraged with each resident having a water jug and being offered additional drinks as required. Medication management requires some attention; most medicines are managed accordingly and given as prescribed. However, it was evident from a review of the administration records that there were gaps in signatures thereby not indicating whether the medicine had been given or omitted. These medicines could not be effectively audited as some did not have a record of the date the medicine box or bottle was started. One resident had been prescribed a course of 21 anti-biotics, records indicated that 20 had been given and the box was empty. DS0000020496.V303316.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good, this judgement is made using available evidence including a visit to this service. Social care assessments provide staff with basic information concerning individual social and leisure choices and residents were content with the homes social arrangements. Residents are supported in maintaining contact with their friends and family but there was no evidence that residents are engaged in making informed decisions about their lives in the home. A variety of meals are prepared for residents although further consideration needs to be given to addressing individual nutritional requirements. EVIDENCE: A written schedule of activities, or ‘activities programme’ was not examined although it was evident from discussion with residents that they were satisfied with their social arrangements, much of which is self-determined with books, magazines, television or radio. All residents stay in their rooms during the day and although the lounge area is available , residents choose not to use it unless for a specific, planned activity; the deputy manager confirmed that a weekly ‘flexicise’ group is enjoyed by some residents as on the day of DS0000020496.V303316.R01.S.doc Version 5.2 Page 14 inspection. Care records also demonstrated when residents received visits from friends and families. Although residents confirmed that they are comfortable in the home and are happy with the daily routines, there was no evidence that residents are supported in making personal choices and decisions about their lives through consultation with the assessment and care planning process. A four-week menu is available although it was evident that this is not adhered to, therefore residents do not know what meal is to be served from day to day. The deputy manager confirmed that meals are prepared from available stock and where if it is known that a resident has a particular dislike for a meal, an alternative is prepared for them. Breakfasts and evening meals are prepared by individual choice with residents being asked what they would like beforehand, a list of evening meal choices for the day of inspection included various sandwiches, soups, salad or something light on toast. Food stores were seen and noted to contain a range of fresh fruit and vegetables and supermarket value products. Residents spoken with who were able to comment, all confirmed that the provision of food was good and that meals were appetising. Comment has been raised in this report under standard 7 regarding nutritional assessments for residents; this needs to be considered alongside menu planning in the home. DS0000020496.V303316.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor, this judgement is made using available evidence including a visit to this service. The home’s complaints procedure is not available to residents who cannot therefore be assured that their concerns or complaints will be listened to Procedures for responding to suspicions of abuse are not held in accordance with Department of Health guidance and staff have not received training, meaning that any allegations of abuse cannot be managed effectively. EVIDENCE: St Annes complaints procedure is written into the Service User Guide which is not available to residents. The procedure for managing complaints is held in the policies and procedures file, and states that any complaints should be addressed to the manager. In the manager’s absence, as on the day of inspection, is was evident that staff did not know the procedure for managing a complaint or know the location of the complaints forms. All questionnaires returned form residents confirmed that they would know who to complaint o if they were unhappy, three of the four returned from relatives confirmed that they had not received a copy of the home’s complaints procedure. The deputy manager stated that as far as she was aware, the manager had received no complaints and that any minor concerns raised are dealt with at the time. A copy of the Local Authority guidance ‘No Secrets’ was held in the office although staff confirmed that they had not heard of this document and had not received training. The home’s internal policy does not refer to this guidance DS0000020496.V303316.R01.S.doc Version 5.2 Page 16 and instructs that any allegation must be referred to the proprietor (manager) who will ‘take appropriate action’, it is not specified what this action is and therefore, in the absence of the manager, guidance is not available for staff to deal with allegations received. DS0000020496.V303316.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24 & 26 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. Accommodation at St Anne’s is safe and well maintained. Residents are able to benefit from comfortable, well furnished, clean and hygienic surroundings with some of their own belongings around them. EVIDENCE: St Anne’s presents as a well maintained, safe environment, a fire risk assessment has been carried out and fire precautions are observed, a schedule of maintenance was not reviewed although it was evident that the premises were kept up to standard, well equipped and decorated and suitable for the purpose of residential and nursing care. Maintenance of equipment was evident through PAT* testing and servicing labels affixed to the equipment. Communal areas of the home are accessible although none of the residents choose to take advantage of this preferring to spend time in their rooms. There is a lounge area but no dining room and gardens to the front and rear of the DS0000020496.V303316.R01.S.doc Version 5.2 Page 18 home. The lounge area is comfortably furnished and well decorated although is used more as a staff room with office space at one end where records are held. Some social activities take place in this area when residents are able to gain easy access. At the time of inspection, the rear gardens were being cleared as the deputy managed explained the plans for improvement of this area. At the front of the home there is off road parking. Eight of the single rooms have en-suite facilities and all rooms have wash hand basins. There are bathrooms, showers and toilets sited around the home for the convenience of residents, a requirement of the last inspection that bathroom doors have locks to protect residents privacy is repeated as a recommendation as although locks have not been fitted, vacant/engaged signs have been placed on all doors. Residents bedrooms visited were all clean, well furnished and pleasantly decorated; many residents had taken the opportunity of personalising their rooms with pictures and ornaments etc. Rooms provide sufficient space for residents use and where specialist equipment is needed for care routines such as hoists, there was sufficient space around the beds for their use. One ground floor bedroom has a curtain rail with curtain that serves no purpose. The curtain is in an arc around the bed head; this should be removed as Mrs Lingham-Wilgoss advised it would be at the last inspection. The home’s laundry is sited in the rear garden, the laundry room is fit for its purpose having two commercial style machines with sluicing programmes and capable of reaching temperatures of 95°C, and two tumble dryers, in good weather laundry is line dried outside. Residents confirmed that the laundry system works well with clothing being returned clean and in good condition. Other aspects of the home’s cleanliness and hygiene are satisfactory with staff being provided with appropriate hand-washing facilities to prevent the spread of infection. *PAT – Portable Appliance Test DS0000020496.V303316.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 Quality in this outcome area is adequate. This judgement is made using available evidence including a visit to this service. There are sufficient numbers of staff on duty in the home each day and night to provide the level of care and support needed by residents. Staff training programmes are in place but must be developed to ensure the staff group has the skills and knowledge they need to meet resident’s needs. Staff recruitment procedures could not be evidenced as records were unavailable. EVIDENCE: Although staff rotas were not examined and pre-inspection information requesting this information was not sent, it was evident from speaking with residents and from direct observation, that there were sufficient numbers of staff on duty. On arrival at the home, there was one trained nurse, the deputy manager (also a trained nurse) and three care staff along with two domestic staff and a cook. During the afternoon there was one trained nurse, three carers and the deputy manager until 3.00pm. Residents spoken with confirmed that there were always sufficient staff on duty to meet their needs. Four care staff are currently doing an NVQ level 2 in care, two staff are doing level 3. DS0000020496.V303316.R01.S.doc Version 5.2 Page 20 Standard 29 could not be assessed as the deputy manager said staff files requested for recently appointed staff were unavailable, as Mrs LinghamWilgoss had ‘probably’ taken them home. An induction programme is available for new staff, a review of this demonstrated that the induction covers areas including health and safety, use of equipment, patient care, emergency and record keeping procedures. The induction record is a checklist with space for the new staff member and trainer to sign to confirm these areas have been discussed. The induction programme is not held in accordance with National Occupational Standards for care staff and the level of learning is not measurable. Mrs Lingham-Wilgoss is advised to look at the following web sites for further information about staff training programmes: www.picbdp.co.uk www.skillsforcare.org.uk www.traintogain.gov.uk www.lsc.gov.uk/bdp/employer/eggt_intro.htm Staff training records examined evidenced the following training had been provided to the given number of staff: First Aid – 14 staff Safe Handling of Medicines – 4 staff Moving and handling – 13 staff Catheterisation – 6 staff Food Hygiene – 3 staff Health and safety – 2 staff Infection control – 1 staff Several other courses had been undertaken in relation to specific practices such as wound care and dysphasia. (See also standard 38) A recommendation of the last inspection is repeated as a requirement and a requirement regarding adult protection training is repeated for the second time as during this inspection, it was evident that the deputy manager was not aware of the adult protection protocol and two staff members said that ‘abuse’ was covered as part of their NVQ, staff not undertaking NVQ training have therefore not had training in this area. DS0000020496.V303316.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37 & 38 Quality in this outcome area is poor. This judgement is made using available evidence including a visit to this service. The owner/manager at St Anne’s has achieved the expected standard of management training. Quality assurance programmes and audits are beginning to take shape but must be developed to ensure controlled measurement of care and services provided in order that the home meets its expressed aims and objectives. The deputy manager confirmed that the home does not take responsibility for the management of any resident’s finances. Records required by regulation for the protection of residents were not all available for inspection. The health and safety of residents is protected to some degree by maintenance and servicing of equipment in the home although is let down by poor staff training programmes. DS0000020496.V303316.R01.S.doc Version 5.2 Page 22 EVIDENCE: Mrs Lingham-Wilgoss has owned and managed St Anne’s for many years and has achieved NVQ level 4 Registered Managers Award. The deputy manager confirmed that Mrs Lingham-Wilgoss is approachable and always available at the end of the phone when she is not in the home. This inspection has highlighted several areas of concern however where it would be prudent of Mrs Lingham-Wilgoss to review her management approach to ensure requirements are addressed and working systems are in place that are in accordance with National Minimum Standards. The deputy manager confirmed that questionnaires had been sent to residents, relatives and care professionals associated with the home to gain their views on the service provided and that any responses to these had been reviewed by Mrs Lingham-Wilgoss. Additionally, the deputy manager confirmed that she has started to do an internal ‘audit’ which is recorded in a diary, she has started to visit residents in their rooms to obtain their views, the records of such visits indicated the name of the resident, the room number and a comment such as ‘no concerns’ or where a minor concern regarding food for example was received. The deputy manager has also undertaken an evaluation of the home’s medication system although in view of the findings of this inspection, this needs to be reviewed. There are no formal audits in place and no development plan has been produced. On 1st April 2006 a change in the regulation introduces a legal requirement for registered providers to produce an Annual Quality Assurance Assessment (AQAA), this will be introduced to care homes in autumn 2006. Although the Commission will introduce a set proforma to care homes, it would be considered good practice for the registered persons to consider how well, in their estimation, they deliver good outcomes for residents at St Anne’s including the views of users, where improvements can be made and what action will be taken to respond to requirements and recommendations of the inspection. Whilst it is expected that on an unannounced inspection, the registered persons may not be present, the person in charge of the home must have access to records required by regulation. The deputy manager could not locate staff recruitment records or staff fire training records stating that Mrs LinghamWilgoss had taken them home. Removing records from the premises compromises their security and confidentiality. Of records that were examined, several requirements have been made as a result of this inspection where recorded information could be improved to ensure it is up to date and accurate. The health and safety of residents is protected to some degree by procedures ensuring that equipment is checked and maintained. Regarding resident’s health and safety, see also standards 7 & 8 concerning risk assessments. DS0000020496.V303316.R01.S.doc Version 5.2 Page 23 Records were available to demonstrate regular testing and maintenance of fire alarms systems and equipment although staff fire training records could not be reviewed. Staff training in health and safety related subjects must be improved as available records demonstrate that just three staff have attended food hygiene courses, two have attended a general health and safety course, and just one has received training in infection control procedures and COSHH* *COSHH – Control of Substances hazardous to Health Regulations 2002 DS0000020496.V303316.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 3 3 X 3 2 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X X 1 1 DS0000020496.V303316.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement The home’s Statement of Purpose and Service User Guide must contain all the information as referred to in Schedule 1, Care Homes Regulations 2001 and must be available to all current, and prospective residents of the home. The registered persons must ensure there is a system of identifying the source of information obtained at the preadmission assessment process and that the resident or their representative is party to the process indicating their agreement with the outcome. Previous time-scale 31/03/06 not met, this requirement is repeated for the second time. Where a service user is in receipt of catheter care, a care plan must be available detailing the action to be taken, when, by whom and how often. Previous time-scales not met 07/07/05 and 31/03/06. This is the third time this requirement is repeated. DS0000020496.V303316.R01.S.doc Timescale for action 1 OP1 4&5 31/08/06 2 OP3 14 31/08/06 3 OP7 14 31/08/06 Version 5.2 Page 26 4 OP8 14 5 OP7 14 6 OP9 13 7 OP16 22 8 OP18 13 9 OP30 18 10 OP31 10 Where nutritional assessments identify the person at a ‘very high risk’, action must be taken as necessary to reduce this risk and must be fully documented. Daily records, or reports, must demonstrate care as given, where these referred to ‘as planned’; plans must identify adequately what care is to be delivered. Medicines must be managed accordingly and records must demonstrate that which are received, administered and disposed of when no longer required. These records must demonstrate an audit trail of medicines in the home. The home’s complaints procedure must be available to residents and their representatives, procedural guidance must be available for staff detailing how any complaint received is to be managed to a satisfactory conclusion. Clear policy guidance must be available for staff relating to issues of adult protection and staff must be directed to report any incidents or allegations to the correct authority. Staff must receive training in adult protection and prevention of abuse. In order to demonstrate that staff employed are competent and have the skills to do their jobs, the registered persons must have evidence that the induction training meets National Occupational Workforce Training targets. The registered manager must review management practices to ensure minimum standards are maintained. DS0000020496.V303316.R01.S.doc 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 Version 5.2 Page 27 11 OP30 18 12 OP33 24 13 OP37 17 14 OP38 13 All staff must undertake training in adult protection including reporting procedures should any form of abuse or neglect be suspected. Previous time-scale 31/03/06 not met, this requirement is repeated for the second time. The registered persons must establish and maintain a system for reviewing and improving the quality of care in the home, a report of any such review must be provided to the Commission and be available to service users. Previous time-scale 31/03/06 not met, this requirement is repeated for the second time. Records in the home must be secure, up to date, accurate and in good order and must be constructed and maintained in accordance with the Data Protection Act 1998 and other statutory requirements. All staff must receive training in health and safety subjects relevant to their roles within the home including food hygiene, health and safety, infection control and COSHH. 31/08/06 31/08/06 31/08/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP15 Good Practice Recommendations It is recommended that residents are provided with a menu in order that they can make an informed choice about the meals they receive, where a menu is included in the Service User Guide, this should either be accurate or be marked ‘sample menu’. DS0000020496.V303316.R01.S.doc Version 5.2 Page 28 1 2 3 4. OP24 OP24 OP27 Bathroom doors should be fitted with locks to ensure the protection of resident’s privacy and dignity. The redundant curtain rail and curtain in the ground floor room should be removed. Staff roles should be identified on the duty rota to show in what capacity they are working. This recommendation is repeated as rotas were not examined during this inspection. DS0000020496.V303316.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000020496.V303316.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!